Escalation related decision-making in acute deterioration: A retrospective case note review
Escalation related decision-making in acute deterioration: A retrospective case note review
Aim To describe how decision making inter-relates with the sequence of events in individuals who die during admission and identify situations where formal treatment escalation plans (TEPs) may have utility.
Design and methods A retrospective case note review using stratified sampling. Two data analysis methods were applied concurrently: directed content analysis and care management process mapping via annotated timelines for each case. Analysis was followed by expert clinician review (n=7), contributing to data interpretation.Sample 45 cases, age range 38–96 years, 23 females and 22 males. Length of admission ranged from <24 hours to 97 days.
Results Process mapping led to a typology of care management, encompassing four trajectories: early de-escalation due to catastrophic event; treatment with curative intent throughout; treatment with curative intent until significant point; and early treatment limits set. Directed content analysis revealed a number of contextual issues influencing decision making. Three categories were identified: multiple clinician involvement, family involvement and lack of planning clarity; all framed by clinical complexity and uncertainty.Conclusions The review highlighted the complex care management and related decision-making processes for individuals who face acute deterioration. These processes involved multiple clinicians, from numerous specialities,often within hierarchical teams. The review identified the need for visible and clear management plans, in spite of the frame of clinical uncertainty. Formal TEPs can be used to convey such a set of plans. Opportunities need to be created for patients and their families to request TEPs, in consultation with the clinicians who know them best, outside of the traumatic circumstances of acute deterioration.
1-11
Campling, Natasha
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Cummings, Amanda
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Myall, Michelle
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Lund, Susi
239a4d54-13e1-4d69-8e3f-08475c20af47
May, Carl
17697f8d-98f6-40d3-9cc0-022f04009ae4
Pearce, Neil W.
6e450393-03db-472b-9231-1aa2e39b0565
Richardson, Alison
3db30680-aa47-43a5-b54d-62d10ece17b7
Campling, Natasha
0e0410b0-a9cd-486d-a51f-20d80df04791
Cummings, Amanda
7c5f6bd2-979b-456d-9368-8edd13c06691
Myall, Michelle
0604ba0f-75c2-4783-9afe-aa54bf81513f
Lund, Susi
239a4d54-13e1-4d69-8e3f-08475c20af47
May, Carl
17697f8d-98f6-40d3-9cc0-022f04009ae4
Pearce, Neil W.
6e450393-03db-472b-9231-1aa2e39b0565
Richardson, Alison
3db30680-aa47-43a5-b54d-62d10ece17b7
Campling, Natasha, Cummings, Amanda, Myall, Michelle, Lund, Susi, May, Carl, Pearce, Neil W. and Richardson, Alison
(2018)
Escalation related decision-making in acute deterioration: A retrospective case note review.
BMJ Open, 8 (8), , [e022021].
(doi:10.1136/bmjopen-2018-022021).
Abstract
Aim To describe how decision making inter-relates with the sequence of events in individuals who die during admission and identify situations where formal treatment escalation plans (TEPs) may have utility.
Design and methods A retrospective case note review using stratified sampling. Two data analysis methods were applied concurrently: directed content analysis and care management process mapping via annotated timelines for each case. Analysis was followed by expert clinician review (n=7), contributing to data interpretation.Sample 45 cases, age range 38–96 years, 23 females and 22 males. Length of admission ranged from <24 hours to 97 days.
Results Process mapping led to a typology of care management, encompassing four trajectories: early de-escalation due to catastrophic event; treatment with curative intent throughout; treatment with curative intent until significant point; and early treatment limits set. Directed content analysis revealed a number of contextual issues influencing decision making. Three categories were identified: multiple clinician involvement, family involvement and lack of planning clarity; all framed by clinical complexity and uncertainty.Conclusions The review highlighted the complex care management and related decision-making processes for individuals who face acute deterioration. These processes involved multiple clinicians, from numerous specialities,often within hierarchical teams. The review identified the need for visible and clear management plans, in spite of the frame of clinical uncertainty. Formal TEPs can be used to convey such a set of plans. Opportunities need to be created for patients and their families to request TEPs, in consultation with the clinicians who know them best, outside of the traumatic circumstances of acute deterioration.
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Escalation related decision-making in acute deterioration
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Escalation related decision-making in acute deterioration: A retrospective case note review
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Accepted/In Press date: 6 July 2018
e-pub ahead of print date: 17 August 2018
Identifiers
Local EPrints ID: 422465
URI: http://eprints.soton.ac.uk/id/eprint/422465
ISSN: 2044-6055
PURE UUID: 4ea890eb-c9c1-4ca2-bee2-434f870c8152
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Date deposited: 24 Jul 2018 16:30
Last modified: 16 Mar 2024 04:22
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Author:
Susi Lund
Author:
Carl May
Author:
Neil W. Pearce
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